Labor & Delivery Flashcards
1st stage of labor
True labor to complete cervical dilation (10 cm)
Complete cervical dilation
10 cm
In which labor stage do the phases of labor occur?
First stage
Latent phase of labor
0-5 cm, longest, begins w/ onset of regular contractions which become established and increase in frequency/duration/intensity but usually remain mild
Active phase of labor
6-10 cm, faster, esp multiparous
Contractions more frequent & intense (moderate to strong per palpation)
Transition phase of labor
8-10 cm, quickest, may vomit shake, become anxious
Intense, frequent contractions
aka deceleration phase
Second stage of labor
Cervical dilation to 10 cm in preparation for birth; seen with cervical effacement
Cervical effacement
Thinning of cervix
Cervical dilation
Opening of cervix
Third stage of labor
Birth to placental separation/expulsion
Fourth stage of labor
First 4 hours after delivery
In what stage of labor does crowning occur?
Second stage
What position should the fetus be in during the latent phase of labor?
Head at the internal cervical os but cervix is still closed to maintian integrity of amniotic sac
What causes cervical dilation?
Rippling effect from repetitive uterine contractions pulling it and stretching it open
What may be a sign of transition from the latent to active phase of labor in the birthing person?
Contractions become more intense and they’re breathing deeply/having difficulty speaking
How can you gauge the strength of a contraction?
Palpate abdomen at tip of fundus and compare to other body parts
What does palpating a mild contraction feel like?
Tip of nose
What does palpating a moderate contraction feel like?
Tip of chin
What does palpating a strong contraction feel like?
Forehead consistency
How long between contractions is needed to reperfuse/reoxygenate fetus?
60 seconds
What may happen to fetal heart rate as contractions increase in frequency/intensity?
Decelerate
After 5-6 cm, which birthing persons dilate quickly?
Primi- or multiparous
After 5-6 cm, which birthing persons dilate slower & at what rate?
Nulliparous; 1 cm q1-2 hours
What are the 6 P’s of birth?
Passageway (birth canal) Passenger (fetus, placenta) Powers (contractions) Position (maternal) Psyche Pain
Define pelvimetry
Measure between ischial spines
4 pelvic shapes
Gynecoid (optimal)
Platypelloid
Android (resembling male)
Anthropoid
What pelvic shape favors the occiput posterior position?
Anthropoid
What makes gynecoid pelvis optimal for vaginal delivery?
It’s wider side-to-side than front-to-back, parallel sides, dull ischial spines, pubic arch 90 degrees or wider
What is a posterior occiput (OP) birth?
Baby born face up
What are potential complications of OP birth?
Fetal elongation altering FHR
Apneic episodes causing low APGAR scores
Why is android pelvis problematic?
Too narrow, usually does not progress to vaginal birth; if so, may have occipital bruising
Why is platypelloid pelvis not conducive to vaginal delivery?
Fetus has to pass through pelvis with head in a transverse/sideways position
How is cervical effacement measured/documented?
By percentage; 0% (long/thick, 40 mm) to 50% (20 mm) to 100% (paper thin)
Where is an incision made for a C-section?
In the lower 1/3 of uterus w/ direction of muscle fibers
What is the dividing line of the upper 2/3 and lower 1/3 of uterus called?
Physiologic retraction ring
What happens to the upper uterus during labor contractions?
Thickens
What happens to the lower uterus during labor contractions?
Thins and is pulled upward
Why does amniotic rupture cause pain?
Loss of cushion and fetal head begins pressing directly on cervix
How do dilation & effacement differ in nulli- vs multiparous birthing persons?
Nulliparous - complete effacement before dilation
Multiparous - effacement & dilation may occur simultaneously
What are important aspects of the fetus to assess/monitor?
Fetal: head, attitude, lie, presentation, position, station, engagement
3 major parts of the fetal head
Face (well fused)
Base of skull (well fused)
Vault of cranium) (not fused)
How can a fetus head squeeze through the birth canal?
Sutures can override one another, allowing caput molding to pass through
Which is larger, anterior or posterior fontanelle?
Anterior
How might you be able to determine which direction the fetus is looking?
Location of fontanelles
Define fetal attitude
Relation of the fetal parts to one another
Normal fetal attitude
Chin flexed to chest, extremities flexed into torse
Non-normal fetal attitude
Chin extended away from chest, head tilted to one side, extremities extended
Define fetal lie
Relationship of fetal long axis to maternal long axis
Longitudinal lie
Fetal spine is parallel to maternal spine
Transverse lie
Fetal spine is perpendicular to maternal spine
Transverse lie complications
Shoulder presenting so may require C-section if fetus does not spontaneously rotate
Define fetal presentation
Part of fetus entering pelvic inlet first & leading through birth canal during labor
Possible fetal presentations
Vertex/occiput (normal head first), breech (feet or sacrum first), shoulder (scapula), face, brow, chin (mentum)
Which fetal presentation is optimal for vaginal birth?
Vertex/occiput
Which fetal presentation(s) likely require C-section?
Face, breech, shoulder
What is a clue it may be a face or breech presentation?
If you can put your finger in a hole –> mouth (face) or anus (breech)
What are some signs of a brow, face, or undiagnosed breech presentation?
Higher FHR, abnormal contractions
Define compound presentation
Presentation of extra body part near presenting fetal part such as a hand or foot
Types of breech presentations
Complete, incomplete, frank
Why can breech births be complicating for the fetus?
When a fetus’ limb feels cold, it wants to take its first breaths which can lead to apnea
Which position can a face presentation be delivered in?
Mentum/chin anterior only
Define fetal position
Relationship of presenting part of fetus to four maternal pelvic quadrants
How is fetal position documented?
By 3 letters:
1) R or L side of maternal pelvis
2) O, S, M, Sc (presenting fetal part)
3) A, P, T (transverse) (part of maternal pelvis)
What is the most common fetal position?
OA = occiput anterior
Define fetal station
Relationship of presenting fetal part to reference line at ischial spines of maternal pelvis
Measurement of fetal descent in cm
Where is station 0 in terms of fetal station?
At ischial spines
What indicates a minus station?
Fetal station above ischial spines
What indicates a plus station?
Fetal station below ischial spines
What is the range of fetal station?
-5 to 0 to +5
Define fetal engagement
Largest diameter of presenting fetal part reaches/passes through pelvic inlet; cannot be moved out of it
What measurement is used for fetal engagement in vertex/occiput presentations?
Biparietal diameter
What is a term biparietal diameter and what does it indicate?
9.25 cm; fetal head size
What measurement is used for fetal engagement of a breech presentation?
Intertrochanter diameter
What is the smallest and most critical anteroposterior diameter?
Suboccipitobregmatic diameter (nl = 9.5 cm)
Define contractions
Rhythmic tightening & shortening of uterine muscles during labor
Define contraction duration
Beginning to completion of one contraction
Define contraction frequency
Time between beginning of one contraction & beginning of next contraction
Define contraction intensity
Strength of uterine contraction in mmHg
How is contraction intensity measured?
Mild, moderate, strong
Early labor contractions
25-40 mmHg
Active labor contractions
50-70 mmHg
Transition phase contractions
80-100 mmHg
Second (pushing) stage contractions
> 100 mmHg
Second stage of labor characteristics
Complete cervical effacement & dilation
Contractions q1-2mins, 90 sec, strong
Fetal descent stimulates urge to push
Lasts 2 hrs (primi) or 30-40 min (multi)
What type of pushing is recommended for birthing persons?
Open glottis pushing (grunting, yelling, exhaling)
How long can a birthing person hold their breath before O2 delivery to the fetus declines?
7 seconds
What station should the fetus be at before pushing begins?
+2
What may crowning feel like for the birthing person?
Burning, tearing, pressure, pain
What might the birthing person feel during second stage of labor?
Relief to be able to push & birth is near
Pain w/ pushing
Helpless, fearful, irritable
Accomplished
*Provide reassurance & encouragement
What device is used to measure contractions?
Intrauterine pressure catheter
Characteristics of contractions
Increment (buildup)
Acme/Peak
Decrement (regression)
At what contraction intensities does uterine blood flow stop?
40-60 mmHg
Define cardinal movements/mechanisms of labor?
How a fetus navigates the birth canal
Define fetal descent
Progress of presenting fetal part through the pelvis
How is fetal descent measured?
By station
Define fetal flexion
Fetal head meets resistance at pelvis/cervix causing flexion to decrease diameter
Define internal rotation of the fetus
Fetal occiput rotates to lateral anterior position in corkscrew motion to pass through pelvis
Define fetal extension
Fetal occiput passes under symphysis pubis and head extends anteriorly as it is born
Define external rotation of the fetus
After head is born, rotates to position it occupied in pelvic inlet in alignment w/ fetal body and then does a 1/4 turn to transverse position as anterior shoulder passes under symphysis pubis
Define fetal expulsion
After birth of head/shoulders, trunk is born by flexion toward symphysis pubis
What are some common maternal positions?
Lithotomy - feet up in stirrups
Semi-sitting w/ pillows underneath knees, arms, back
Lateral/side-lying w/ curved back & upper leg supported by partner
Hydrotherapy - shower, tub
What maternal positions can gravity assist w/ fetal descent?
Upright, sitting, kneeling, squatting
Advantages of birthing stool
Opens pelvis, gravity, helps pushing
Advantage of squatting
Gives birthing person sense of control
Why are frequent position changes helpful?
Increase comfort, relieve fatigue, promote circulation
What determines position during second stage of labor?
Maternal preference, provider preference, condition of birthing person & fetus
What are some things to avoid with water births?
Do not put baby back into water once out as it is breathing independently
Do not deliver placenta into water
How can the birthing person’s emotional state influence labor?
Catecholamines can affect uterine contractions, slowing labor, due to decreased uterine blood flow
Types of labor pains & when they occur
Visceral - 1st stage (T10-L2, fundus of uterus level)
Somatic - late 1st/2nd stage (S2-S4)
Factors influencing labor pain
Young maternal age, hx of dysmenorrhea, fetal position, large maternal and/or fetal weight, nulliparity
At what spinal level is an epidural typically given?
L3-L4; higher needs different meds to avoid respiratory complications
What are characteristics of labor analgesics to consider?
Maternal/fetal safety, ease of admin, consistent/predictable/rapid onset, allowing maternal movement, retention of maternal expulsive efforts
Types of labor analgesics
Opioids - fentanyl, morphine (need to give at certain time b/c affects fetus)
Antagonist-agonist opioids - nubain
Epidural - pain med + anesthetic
Spinal - similar to epidural
Pudendal block - lidocaine
Local anesthesia - lidocaine
Where is the pudendal nerve located?
Ischial spines
Where is the epidural space relative to the spinal space?
Inferior to spinal space
What is a common complication of an epidural?
Headache, may require blood patch
What are Leopold maneuvers?
Abdominal palpation of fetal presenting part, lie, attitude, descent, and probable location where fetal heart tones can be best auscultated
What are two types of external fetal monitors?
External electronic monitoring (tocotransducer)
External fetal monitor
What does an external electronic monitor (tocotransducer) do?
Applied over fundus to display contraction patterns
Must be repositioned w/ maternal movement
What does an external fetal monitor measure?
FHR patterns during labor, birth
Advantages of external fetal monitors?
Easy to apply, quicky evaluation
Disadvantages of external fetal monitors
Difficult in birthing persons with more adipose tissue or fetus is in awkward position
Advantage of internal fetal monitors
More accurate than external monitors
Disadvantages of internal fetal monitoring
Increases risk of infection for birthing person & fetus
Fetal scalp electrode (FSE) must avoid soft spots (fontanelles), eyes, etc
Characteristics of true labor
Regular & increase in duration, intensity
Discomfort begins in back and radiates to front of abdomen
Intensified by walking
Resting/relaxing in warm water does not decrease intensity
Cause cervical dilation
Fetal engagement
What does progesterone do during labor/delivery?
Relaxes smooth muscle tissue
What does estrogen do during labor/delivery?
Stimulates uterine contractions
What hormones mostly stimulates uterine contractions?
Oxytocin
What do prostaglandins do during labor/delivery?
Contract smooth muscle
Cervical ripening
When estrogen drops after delivery, what hormone sharply increases?
Prolactin for milk production
Why is it important to not skip feedings overnight if breastfeeding?
Can cause estrogen increase which inhibits PRL and decreases milk production
Can also cause ovulation and possible pregnancy so effective contraception use is vital
When is the placenta typically delivered?
~30 minutes after delivery of fetus
What is uterine tamponade?
Intense contraction to push out placenta
What is uterine atony?
Lack of uterine contraction
How much blood can a birthing person lose per minute during delivery?
1000 mL/cc
What can be used to assist in placental delivery?
IV oxytocin
How often should maternal temperature be checked?
q2hrs if membranes ruptured
How do you assess fetal wellbeing during L&D?
FHR
What is assessed during a vaginal exam during L&D?
Dilation & effacement
Fetal descent & station
Fetal position, presentation, & lie
Membranes - intact or ruptured
Nursing assessments during labor
Maternal health hx Physical assessment Fetal assessment Labs Pysch assessment
Labs collected during labor
GBS - IV penicillin if (+)
Urinalysis (clean catch) - dehydration, ketonuria, proteinuria, glucosuria, UTI
Blood tests - CBC, ABO/Rh typing
Signs of symptomatic hemorrhage
SOB, orthostatic hypotension
1st stage assessments
Review prenatal hx/labs Labor status Fetal status Maternal status Culture, language, religion VS Labs Weight at last prenatal visit Edema, proteinuria Fundus Hydration status Level of fatigue
Active phase assessments
See L&D admission assessment
Birthing person & support person may need more direction, encouragement, confirmation
Comfort measures
3rd stage assessments & interventions of birthing person
Meet newborn Placental delivery Fundus tone Answer questions, educate Relax abdomen Prepare meds if PP hemorrhage anticipated
3rd stage assessments & interventions for newborn
Resuscitation as needed - ABCs!
1 & 5 min Apgar scores
Ensure warmth, skin-skin contact
Initiate breastfeeding
Get acquainted w/ parents/family
If fundus is boggy in 3rd stage, what should the nurse do?
Massage to express clots
If not responding, give meds -IM or IV Pitocin -IM methergine (not w/ HTN) IM hemabate -Rectal, vaginal Cytotec
4th stage assessments for birthing person
q15mins for 1st hour - pain, VS (esp BP), fundus, lochia, bladder, perineum, hemorrhage, bonding & breastfeeding
BP drops to pre-pregnant level
HR 60-90, slightly lower than labor
RR 12-20, easy, quiet
4th stage interventions for birthing person
Educate, answer questions
Assist parents in exploring newborn
Assist w/ breastfeeding
Assist w/ elimination
Comfort measures/position, perineum, pain meds
Fluids, nutrition
Allow birthing person/family to debrief L&D experience
When should BP & HR be assessed after delivery?
q15mins for 2 hrs after birth
When should temp be assessed after delivery?
q4hrs for first 8 hrs then at least q8hrs
