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N 106 Labor and Delivery. Female external genitals.

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Presentation on theme: "N 106 Labor and Delivery. Female external genitals."— Presentation transcript:

1 N 106 Labor and Delivery

2 Female external genitals

3 L&D- the P’s of Labor Power uterine contractions maternal pushing Passage bony boundaries of pelvis softening of cartilage linking pelvic bones Passenger lie attitude presentation occiput brow, face shoulder sacrum position – LOA,ROP Psych

4 Uterine muscle layers. Muscle fiber placement. POWER

5 Pelvic types: gynecoid, android, anthropoid, platypelloid PASSAGE

6 Typical anteroposterior diameters of the fetal skull. PASSENGER

7 LIE The relationship of the long axis of the fetus to the long axis of the woman 99% the lie is longitudinal and parallel Transverse lie – fetus is at right angle to mother Transverse lie - uncommon

8 ATTITUDE Fetal attitude is the relationship of fetal body parts to itself. flexed extension Flexion is normal

9 PRESENTATION Cephalic Vertex presentation. Breech presentation. The fetal part that first enters the pelvis

10 Cephalic presentations Occiput/vertex Military Brow Face

11 Breech presentations Frank Breech Full Breech Footling Breech

12 Position Fetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvis Abbreviations of presenting part is “cuddled” between maternal pelvis LOA, LOP, ROA, ROP, RSA, LMP Occiput, Sacrum, Mentum (chin), Anterior, Posterior

13 Categories of presentation.

14 ABCD Quiz

15 PSYCHE Preparation and information Anxiety and fear decrease coping Culture affects views Both physical and emotional experience Do not “nurse the machines”

16 L&D nursing responsibilities History Antepartal weight gain fetal gest & growth risk factors present status Obstetrical Medical surgical interval Assessment maternal vital signs uterine activity bladder status I&O bloody show response to labor maternal discomfort fetal heart rate Amniotic fluid

17 L&D Leopold’s maneuvers Palpate upper abdomen Palpate opposite side in circular motion for fetal extremities Palpate for engagement of presenting part Palpate to identify cephalic prominence

18 What fetal part is in fundus

19 Palpate for back

20 Palpate for engagement of presenting part

21 Palpate position of head – determine descent & flexion

22 Location of FHR in relation to the more commonly seen fetal positions.

23 Location of FHR in relation to the commonly seen fetal position

24 Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.

25 Intrapartum Fetal Assessment Fetal Heart Rate Electronic Fetal Monitoring ultrasound transducer Response to contractions tocotransducer Internal fetal monitoring – RBOW fetal scalp electrode intrauterine pressure catheters (IUPC)

26 Attached spiral electrode with the guide tube removed.

27 Characteristics of uterine contractions.

28 Normal fetal heart rate pattern obtained by internal monitoring.

29 Fetal Heart Rate Patterns Tachycardia – greater than 160 for 10 min Bradycardia – less than 110 for 10 min Absent or minimal beat-to-beat variability Early decelerations – head compression Late decelerations – uterine placenta insufficiency Variable decelerations – cord compression

30 Comparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern.. A B

31 Types and characteristics of early, late, and variable decelerations.

32 Nursing Interventions for Decelerations Early Continue to observe Late Stop oxytocin Replace fluids Change mother’s position Check B/P and Pulse Administer oxygen Notify physician Variable Stop oxytocin Replace IV fluids Change mothers position Check for prolapsed cord Check B/P and Pulse Administer oxygen Notify the physician Prepare to assist with fetal scalp blood sample

33 Conditions Associated with Fetal Compromise FHR below 100 or above 160 Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smelling Contractions lasting longer than 90 seconds occurring less than 2 minutes apart Maternal hypotension, hypertension, fever

34 Actions to increase oxygen to fetus If receiving Pitocin stop or slow rate Reposition mother Increase non-additive IV fluids Administer 100% oxygen thru snug face mask to mother at rate of 8-10 liters/min Keep mothers bladder empty Change under-pads regularly

35 L & D true vs false labor True labor contractions: Start in back & move wavelike toward abdomen Become more intense with walking Result in ripening of cervix, dilation & effacement False labor contractions: Noticed primarily in abdomen Begin & remain consistent Disappear with walking No change in cervical dilation or effacement

36 To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.

37 Measuring the station of the fetal head while it is descending

38 Mechanism of Labor Engagement / Decent Flexion Internal rotation Extension Restitution External rotation Expulsion

39 Mechanisms of labor.

40 Stages of Labor Stage I cervical dilation to 10 cm & effacement to 100% early/latent active transition Stage II crowning to birth of baby Stage III birth of baby to delivery of placenta Stage IV 1-4 hours after delivery of placenta stabilization recovery

41 Phases of Stage I of Labor Early/latent - dilates - 0-3 cm contractions q 5 min X 30-40 sec Active - dilates – 4 - 7 cm contractions q 2- 5 min X 40-60 sec Transition- dilates – 8-10 cm contractions q 2-3 min apart X 60-90 sec

42 Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.

43 Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.

44 Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.

45 Complete effacement and dilatation. End of Stage 1

46 Friedman Curve Predicable progression of labor for Nulliparous and Multiparous

47 Responsibilities during First Stage of Labor Promote Comfort positioning, lighting temperature, cleanliness bladder, mouth care Relieve pain breathing techniques nonpharmacologic massage, touch, pressure hydrotherapy imagery or focal point

48 Stage 2 From 10cm 100% to birth of Baby Assist mother with pushing Preparation of sterile delivery table Perineal cleansing Sutures for episiotomy or laceration Initial care and assessment of newborn APGAR

49 Effects of labor on the fetal head. Caput succedaneum formation.

50 Care of Infant Maintaining cardiopulmonary function – APGAR Supporting thermoregulation Identifying infant Examining for obvious anomalies and birth injuries Medication administration

51 Clamp is positioned 1/2 to 1 in from the abdomen and then secured.

52 APGAR Heart rate – above 100 Respiratory Effort – spontaneous with cry Muscle tone – flexed with movement Reflex response – active, prompt cry Color – pink or acrocyanosis 0-3 infant needs resuscitation 4-7 Gentle stimulation – Narcan 8-10 – no action needed

53 Cut cord. The one vein and two arteries can be seen.

54 Placenta Separation Stage 3 Uterus changes shape Uterus rises upward in the abdomen Cord begins to move out of the vagina Gush of blood noted from vagina

55 Placental separation and expulsion. Schultze mechanism. Stage III

56 Stage 4 of Labor First 1-4 hours after delivery of placenta Palpate fundus Assess vital signs Assess lochia Ice pack to perineum Care of infant and Care of mother Identification Promoting bonding

57 Suggested method of palpating the fundus of the uterus during the fourth stage.

58 Common Intrapartum Procedures Amniotomy Stimulation of labor induction augmentation Assisted delivery episiotomy forceps vacuum extractor Cesarean delivery

59 Amniotomy Artificial rupture of fetal membranes Advantages decrease some labor assessment of fluid for meconium permits internal monitoring Risks cord prolapse infection

60 Assessment of Fluid Quality, Color, and Odor Greenish, meconium stained Large amount of vernix Strong order, cloudy or yellow Hydramnios Oligohydramnios

61 Prolapse of the umbilical cord. Risk during ROM

62 Induction & Augmentation of Labor During Stage 1 Definitions Criteria – Bishop’s scoring, 39 weeks gest. Methods surgical – amniotomy drugs Oxytocin (Pitocin) – IV stimulate contractions Cervical ripening agents prostaglandin Misoprostol (Cytotec)- tab dinoprostone (Prostin E2) Cervidil/Prepidil - vaginal/cervical gel

63 Episiotomy Most common operation primip – 70% multip – 30% Types midline – most common problem with 3-4 th degree laceration mediolateral increased PP pain, more scaring Main risk – infection Complication of infection – prolonged dysparenia Prevention – perineal massage & stretching beginning at 34 weeks.


65 Lacerations First degree - limited to fourchette, perineal skin, vaginal membrane Second degree - underlying fascia and muscle of the perineal body Third degree – involves the anal sphincter Fourth degree – extends thru the rectal mucosa to lumen of rectum

66 Interventions During Stage 2 Forceps & Vacuum Extraction Assist with decent and rotation of fetal head Risk- trauma to maternal and fetal tissue Criteria scalp is visible at vaginal opening normal scalp ph is above 7.25 Low forceps - station is +2 or lower Mid forceps - station 0 to +2

67 With correct placement of the blades, the handles lock easily. Forceps

68 Vacuum extractor

69 Risks to Mother and Infant Mother laceration hematoma of the vagina Infant ecchymoses facial and scalp lacerations and abrasions cephalhematoma intracranial hemorrhage Chignon –scalp edema from vacuum extractor

70 Cesarean Birth About 22% of all births Indications – dystocia, CPD, PIH, DM, genital herpes, prolapsed cord, fetal malpresentations, placenta previa or abruptio placentae Maternal risk same as any abdominal OR Infant’s greatest risk is lung immaturity

71 Preparation for C/S NPO, get operative permit signed Pre-op teaching Lab work – CBC, clotting series, type and cross match one or more units Single IV dose of antibiotics Famotidine (Pepcid) and citrate (Bicitra) Shave abdomen Insert foley catheter Perform abdominal scrub

72 Incisions for C/S Abdominal incision vertical – umbilicus to symphysis transverse or bikini – above symphysis Uterine incisions low transverse low vertical classic Abdominal and uterine incisions do not always match

73 Low transverse incision

74 classic uterine incision

75 Nursing Considerations C/S Routine assessments q 15 min X 1 hr, q 30 min X 1 hr then hourly VS fundus for firmness, height, deviation lochia urine output abdominal dressing Assess need for pain medication TCDB – support incision with pillow

76 Intrauterine Infection Signs Fetal tachycardia – FHT greater than 169 Maternal fever – greater than 100.4 Foul or strong-smelling amniotic fluid Cloud or yellow appearance to amniotic fluid

77 Nursing Care for Infection Prevention wash hands limit vaginal examinations keep under pads dry Assess VS q 4 hours if ROM than q 2 hrs Collect culture specimens

78 Intrapartum complications Dystocia CPD – cephalopelvic disproportion Placenta previa Abruptio placenta Prolapsed umbilical cord Macrosomia - Shoulder dystocia

79 Dystocia Abnormal progress of labor Contributing factors sedation, anxiety, anesthesia, unripe cervix, supine position, cephlopelvic disproportion - CPD Management depends on cause

80 Complications of Pregnancy Hemorrhage – late in pregnancy Placenta Previa Abruptio Placentae

81 Placenta previa Placenta located over/near cervical opening S&S: painless bleeding in 3 rd trimester, hemorrhage, fetal distress Risk factor: multiparity in older women TX: Hospitalization, bedrest, ultrasound Care: Do not perform vag exam Monitor mother and fetus Prepare for delivery / no oxytocin

82 Placenta previa. Low placental implantation. Marginal (low-lying)

83 Total placenta previa

84 Abruptio Placentae Premature separation of placenta S&S: Concealed or apparent hemorrhage in 3 rd trimester, uterine tenderness, abd Pain, Board like abdomen, shock, fetal distress Risk factors: PIH, multiparty, DM TX: Replacement of blood loss, IV fluids, delivery Care: Explain procedures, monitor mother and fetal condition, prepare for delivery

85 Marginal abruption with external hemorrhage. Abruptio placentae.

86 Complete separation with concealed bleeding. Abruptio placentae

87 Shoulder Dystocia Risk factors diabetes; macrosomic infant obesity prolonged second stage previous shoulder dystocia Morbidity Management

88 Position for prolapse cord

89 Prolapsed Cord Cause – increase risk - high station, AROM, poor fit, hydramnios, breech Signs of prolapse – visible, suspect Management – Emergency - Call Light Reduce cord compression Position hip higher than head Hold fetal part upward Give oxygen 8-10 liters/min Prompt delivery is the priority

90 Other Complications Precipitous delivery Retained placenta Uterine inversion Uterine rupture Umbilical cord problems Multiple births

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