Labor and delivery Flashcards
Factors affecting labor think the 5 Ps
Passenger - infant passageway - bony pelvis and soft tissue powers - intensity of contractions and ability to push position of the laboring woman psychological response
Variables that can influence L&D in regards to the “passenger” head of the passenger
passenger = fetus
- size of the fetus
- the head is the large body surface and it is the hardest
- the skull is comprised of a series of plates with sutures and fontanels between them to allow for shifting and overlapping during labor and rapid infant brain growth in the first year and a half of life
Variables that can influence L&D in regards to the “passenger” shoulders
fetal shoulders can also create dystocia - dystocia - disproportion between infant and pelvis (creating a difficult birth)
- seen in large babies
- especially true with diabetic mothers
Fetal presentation (types)
- refers to the presenting part of the infant in the birth canal
- cephalic
- breech
- frank
- scapula
cephalic fetal presentation
- head first is CEPHALIC
- usually it is the occiput that is the foremost part of the head - the vertex
- occiput presents because chin is by the chest
breech fetal presentation
- if the lower half of the infant is presenting
- does not fill and cork off the pelvis during labor the way the head does
frank breech fetal presentation
- the buttocks down and the legs up or single or double footing
scapula fetal presentation
- a shoulder presenting
what is at risk of happening when the water breaks?
- greater potential for umbilical cord to slip between the baby and the pelvis
what is an obvious sign the patient is having an arrest of labor
- think the head is the biggest part of the body… if labor is not progressing and the baby can’t get through
- breech with a big-headed baby –> body is already through
fetal lie
- refers to the longitudinal orientation of the fetus (spine of the infant in relation to spine of the mother)
longitudinal lie
cephalic of breech position
vertical lie
transverse lie (SHOULDER PRESENTING) BABY CANNOT DELIVER THIS WAY!
Fetal attitude
- refers to flexion of the infant
- if the infant is somewhat curled up with its chin flexed onto its chest, the arms and legs flexed towards the abdomen it is in GENERAL FLEXION (minimizes the diameter of the head)
- extended head or arms can cause problems for the delivery
- breech * need good flexion *
fetal position
- refers to the relationship of the presenting part to the maternal pelvis
- described in three letter codes
- first letter - represents the presenting part’s R or L orientation
- second letter - presenting part
- third letter - the presenting part’s location related to an anterior, posterior, or transverse location
ROP
means right, occipital, back of head posterior in pelvis
what is the optimal position (posterior or anterior)
- ANTERIOR because of the curve and contour of the sacrum
- IDEAL IS OCCIPUT ANTERIOR
when would you have to rotate the baby?
- when occiput posterior reaches points in pelvis for obstruction
- small % of babies are delivered posteriorly
passageway
- is the mother’s bony pelvis and soft tissues
- the bony pelvis is the more significant of these two
- there are multiple contours to the inner pelvis
- soft tissue issues arise with obesity and female circumcision
bones of the pelvis + what is the pelvis comprised of
- the pelvis is comprised of pieces of bone joined by cartilage
bones of the pelvis… - ilium (larger wings)
- ischium (lower segment anterior)
- the pubis (upper anterior)
- sacral bones (scoops from back towards coccyx)
what is the pelvis canal divided into (for OB purposes)
- divided into two segments
- upper pelvis, above the brim - false pelvis, plays no part in childbearing
- lower pelvis (TRUE PELVIS) - divided into three planes
1) inlet
2) mid pelvis
3) the outlet
ischial spines
- create the smallest diameter of the pelvis
* * POINT THAT IS HARDEST TO GET PAST DURING LABOR **
four types of female pelvis names
gynecoid
android
anthropoid
platypelloid
gynecoid
- most frequent and best for birth
android
- resembles the male pelvis
- encourages posterior presentations
anthropoid
- resembling an apes
- difficult for delivery
- very narrow
platypelloid
- a flat pelvis
- very difficult for delivery
- narrow anterior/posterior
shape of pubic symphysis for outlet
- android and anthropoid more narrow and V-shaped outlets
station of the baby in labor
- head in relation to ischial spine (narrowest part of the pelvis)
soft tissue 3
cervix - effaced and dilated to allow passage
pelvic floor muscles - assist the infant in rotating as it descends
vagina and introitus - dilate to accommodate passage
powers of labor
- refers to both the involuntary contracting of the uterine muscle and the voluntary efforts of the mother to expel the fetus at the time of delivery
pacemaker for the uterus
- near the fundus
- contraction starts here and then progresses down the top half of the uterus
- lower half DOES NOT contract but rather draws up toward the top half effacing the cervix and then dilating it
- muscle fibers shorten and pull on the lower half –> migrate upwards causes cervix to dilate
- we assess the UPPER HALF of the uterus
what part of the uterus do we assess
THE UPPER HALF!
how often does the uterus contract/relax
- every few minutes in a rhythmic manner
- as labor progresses contractions tend to grow closer, longer and more intense
how are contractions described
- in terms of frequency, duration and intensity
what/who is the best determiner of the intensity of contractions
- the mother is the best determiner of the intensity of the contractions
- HOWEVER, INTERNAL FETAL MONITORING IS ACCURATE!
how are contractions timed?
from the onset of one to the onset of the next
why is resting very significant in regards to contractions
- allows the reestablishment of full blood supply to the baby
other information: - blood vessels lace through muscle fibers of the uterus
- while the uterus is contracting there is diminished blood flow to the baby
- inductions in labor –> may affect the fetus
position of the laboring woman
- have an impact on both the intensity and effectiveness of the contractions and on the ability of the infant to navigate the contours of the pelvis
- upright position increases the potential for the presenting part to act as a dilating wedge
how can we help move a baby out of a posterior position?
- place mom in position with knee to chest and lateral lying… this will assist in rotating posterior positions
how do physicians historically deliver the fetus position wise
- deliver in the lithotomy position
* ** can diminish blood flow because the baby lies on inferior vena cava ***
physiological response
- a woman’s emotional response to labor can have dramatic effects on her ability to accept labor and work with it to deliver her infant
- anxiety and fear increases the release of catecholamines which can actually slow down labor by impeding contractions
factors that can influence emotional response in labor
- culture
- anxiety
- fear
- previous experience (sexual abuse/molestation)
- childbirth prep
- support
- birth environment
true labor characteristics
- contractions occur at regular intervals
- interval btw contractions gradually shortens
- contractions increase in duration and intensity
- discomfort begins in back and radiates around to abdomen
- intensity usually increases with walking
- cervical dilation and effacement are progressive
false labor characteristics
- contractions are irregular
- no change in interval
- no change in duration/intensity
- discomfort usually begins in abdomen
- walking has no effect on or lessens contractions
- no change in cervical dilation
when does uterus tone itself
- before labor
Ruptures of membrane
- SROM occurs when the water breaks on its own
- this can happen before the onset of labor (PROM), during labor or before
how can a nurse assess for rupture of membrane
- the nurse can assess for ROM using a nitrazine paper (TURNS INDIGO BLUE) or creating a slide to assess for ferning, the characteristic drying pattern of amniotic fluid
artificial rupture of membrane (AROM)
- occurs when MD or midwife INTENTIONALLY breaks the bag of water
- should only be done once the infant is at the -o- (narrows spot of pelvis) station to minimize the potential for the cord to move down beyond the infant’s head
- done w an amnihook
- uterus mass will decrease, allowing it to become smaller and muscle to become denser
what is released during ROM
- PROSTAGLANDIN –> more contractions!
cardinal movements of labor *7
engagement descent flexion internal rotation extension restitution and external rotation
engagement
comes into upper part of pelvis
flexion
head anteflexed with chin toward chest
internal rotation
begins with transition into true pelvis
transverse –> anterior posterior rotation of the head
extension
head extends up and down
restitution and external rotation
occurs as shoulders start to rotate
shoulders have their widest diameter TRANSVERSLY
when is an episiotomy done?
when client has a lot of stretch marks, or short distance from the vagina to the rectum
how is an episiotomy done
cut intentionally made by provider
creates an interruption in muscular layer
attempt to avoid tissues in perineal area
stages of labor *4
first stage - starts with the onset of regular uterine contractions until full dilation of the cervix (10cm)
second stage - lasts from dull dilation until delivery of the infant
third stage - delivery of the infant until delivery of the placenta
fourth stage - from delivery of placenta until 2 hrs later
first stage of labor
latent phase
active phase
transitional phase
latent phase
starts with the onset of regular uterine contractions and lasts until labor progress starts to accelerate (about 3 cm)
Usually the longest
active phase
lasts from initial acceleration at about 3 cm until about 8 cm
Contractions closer, more uncomfortable
transitional phase
- an intense period of more rapid progress which lasts until full dilatation of the cervix
average length of labor
*there is no predicting the length of any give stage
Average labor 14.5 hrs
Subsequent average is 8 hrs
second stage
Involves voluntary and involuntary forces at play together to work toward delivery
Length is highly variable and varies from one contraction to several hours
third stage
Can be allowed to happen spontaneously or encouraged to happen in a timely manner to minimize blood loss
Encouraged with a history of PP hemorrhage or anemic going into delivery
Care must be taken if a more active management approach is taken not to shear off the cord, leave placental fragments behind or invert the uterus
signs that placenta is separating
Advancing the cord Change in the shape of the uterus Change in the location of the fundus Sudden increase in vaginal flow Patient ℅ cramping
shiny schultz delivery of the placenta
starts centrally, clot forms behind it, edges detach –> comes out with shiny fetal side presenting
dirty duncan delivery
Placenta tries to adhere, upper edge tries to stay attached
Maternal side comes out first
Suspicious of retained placental fragments that were not detached → pt must be examined
fourth stage
Involves minimizing bleeding and the repair of any lacerations or incisions
To control hemorrhage, uterine muscle must contract and act as a tourniquet
Medications frequently used to promote uterine contraction in this period include:
pitocin, methergine, cytotec, hemabate
pitocin (oxytocin) route
IV or IM
Methergine route
ONLY IM
longer duration
CONTRAINDICATED WITH HTN HX
cytotec
can also ripen uterus before delivery
often given RECTALLY
hemabate
if hemorrhage is caused from lack of contraction –> hemabate is very effective
IM
CONTRAINDICATED W ASTHMA
N/V diarrhea side effects
origins of discomfort in labor *2
visceral
somatic
visceral
refers to the internal body areas enclosed within a cavity
Visceral pain results from infiltration, compression, extension, or stretching of the viscera
Visceral pain occurs in the first stage of labor from:
Cervical changes
Distention of the lower uterine segment
Uterine ischemia
somatic
caused by the activation of pain receptors in either the cutaneous (body surface) or deep tissues (musculoskeletal tissues)
OCCURS IN SECOND STAGE
Somatic pain in the second stage of labor comes from:
Stretching and distention of the perineum and pelvic floor
Distention and traction of the peritoneum and utero/cervical supports during contractions
Lacerations of soft tissue
what kind of effects/response does pain have
creates both physiological effects and sensory and emotional responses
physiological effects include:
Sympathetic NS activation Increased catecholamine levels BP and HR increase Respiratory pattern changes Pallor Diaphoresis
sensory perceptions
Prickling Stabbing Burning Busting Aching Heavy Pulling Throbbing Sharp Stinging Shooting Cramping
emotional responses
Increased anxiety with lessened perceptual field Writhing Crying Groaning Gesturing Excessive muscular excitability
physiological factors
Hormones
Position
Fetal size and pelvic dimensions
Endorphin levels –>Go up at end of pregnancy
non-pharmacological management includes:
Relaxation Breathing Music Water therapy Acupressure Aromatherapy TENS Touch and massage Effleurage and counter pressure Hypnosis Biofeedback Imagery and visualization Intradermal water block --> Injection of water/saline bilaterally
types of pharmacological pain management
sedatives
analgesia
anesthesia
analgesia
specifically addresses pain
opioid agonist analgesics - fentanyl
co-drugs
co-drugs
Tranquilizers often used to potentiate opioids
Some have antiemetic effects also:
- Vistaril
- Phenergan
opioid antagonists
Given to counteract the effects of narcotics such as CNS depression in mother or baby
–> Narcan
anesthesia
- local nerve blocks - used if anticipating episiotomy
- regional (pudendal block, spinal anesthesia, epidural anesthesia)
- general anesthesia
pudendal block
Regional anesthetic injected vaginally into the nerves which innervate the vagina and perineum
Done in transitional labor or in the second stage
spinal anesthesia
Used w C-section
Spinal needle placed into subarachnoid space with the patient either sitting or lying on her side
Women may develop headache from leaking of CSF
epidural anesthesia
- Used in labor as continuous infusion
- Epidural catheter is placed into the epidural space with the patient either sitting or lying on her side similarly to the spinal
- Catheter is left in place until after delivery for continuous or intermittent dosing
how is pt placed for spinal or epidural anesthesia
sitting or lying on side
general anesthesia
- Used in emergencies
- Approx 3 minutes between the time the mother is anesthetized and the time that the infant starts to receive levels that can cause CNS depression and depressed respirations
MOST COMMON SIDE EFFECT OF ANESTHESIA
HYPOTENSION
- Caused by spinal and epidural anesthesias
- Due to vasodilation in the region affected
- Can result in poor placental perfusion
- Increased IV fluids and positioning again can minimize these effects
- Medications such as ephedrine are used to increase the patient’s BP
fetal assessment
- Done either by electronic fetal monitoring or fetal HR auscultation
- Performed using a hand-held Doppler ultrasound to count the FHR during a uterine contraction and for 30 seconds after to identify fetal response
- Intermittent auscultation protocol calls for auscultation every 30 mins for low risk patients in the active phase of labor
how often would you listen for fetal HR for….
low risk patient
second stage of labor
when indiv is pushing
- every 30 mins for low risk patients in the active phase of labor
- Every 15 minutes in the second stage of labor
- Every 5 mins when pushing
- ** Continuous EFM is indicated when abnormalities are heard
